Clin Geriatr Med 23 (2007) 255270

Abdominal Pain
Ernest L. Yeh, MD, FAAEMa,*,
Robert M. McNamara, MD, FAAEMb
a
Department of Emergency Medicine, Temple University School of Medicine,
Temple University Hospital, 3401 North Broad Street, 1011,
10th Floor Jones Hall, Philadelphia, PA 19140, USA
b
Department of Emergency Medicine, Temple University School of Medicine,
Temple University Hospital, 3401 North Broad Street, 1002,
10th Floor Jones Hall, Philadelphia, PA 19140, USA

The population of the United States is rapidly getting older. According

to the US Census Bureau, approximately one in eight Americans were el-
derly (age O64) in 1994, and about one in ve will be elderly by the year
2030. The number of persons aged 65 years old and older will more than
double by the middle of the next century, to 80 million [1]. Obviously,
the growth of this segment of the population will be accompanied by an in-
crease in the number of patients who seek a medical evaluation for abdom-
inal pain.
This complaint must be considered seriously, because nearly half the pa-
tients older than 65 years who present to the emergency department (ED)
with abdominal pain are admitted, and as many as one third require surgical
intervention at some time during their admission [2,3]. The overall mortality
for elderly ED patients with a chief complaint of abdominal pain exceeds
10%, rivaling that of an acute ST-segment elevation MI [2]. Elderly patients
may initially present to outpatient oces but frequently need additional
evaluation in a more acute setting, either an ED or an inpatient unit. Elderly
patients with abdominal pain who present to the ED typically require more
resources (diagnostic tests, medications, and length of stay in the ED) and
are more often admitted than younger patients [4]. This complaint is fre-
quent: a recent study of 10 northern New Jersey EDs reported that 4.2%
of the visits for those 65 and older were for abdominal pain [5]. In consid-
ering the older patient who has abdominal pain, clinicians should remember

* Corresponding author.
E-mail address: ernest.yeh@temple.edu (E.L. Yeh).

0749-0690/07/$ - see front matter 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.cger.2007.01.006 geriatric.theclinics.com
Descargado de ClinicalKey.es desde Universidad El Bosque febrero 07, 2017. Para uso personal exclusivamente. No se permiten otros
usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.
 256 YEH & MCNAMARA

that the chronologic age may not fully reect the patients physiologic age
and should consider the overall health condition [6].

Diculties in diagnosis
Many factors make diagnosis dicult in elderly patients [7]. These in-
clude diculty in obtaining history from the patient, lack of consistent
physiologic responses (including fever and leukocytosis), and confusing
clinical presentations due to other comorbid conditions [8]. The patients
ability to provide a history is frequently compromised by an altered ability
to communicate. These communication diculties may result from hearing
and vision loss, cerebrovascular accidents leading to receptive or expres-
sive aphasias, Alzheimers disease, and other age-related dementias. Other
barriers to obtaining an adequate history include the patients fear of
loss of independence and stoicism. Altered pain perception in the elderly
may inuence the patients ability adequately to describe and report pain
[9,10].
A number of medications can interfere with the diagnostic process or
may be contributing causes of the presenting abdominal condition. Nonste-
roidal anti-inammatory drugs (NSAIDs), for example, are frequently used
by elderly patients. NSAIDs may block the expected inammatory response
to peritonitis and thereby decrease the degree of abdominal tenderness for
a given pathologic condition, or they may be a contributing source of a per-
forated peptic ulcer. Narcotic use for chronic conditions may also blunt the
pain response that normally signies an intra-abdominal catastrophe. This
eect can cause a delay in the patients presentation or lead the clinician
to underestimate the severity of the condition.
However, the patient whose signicant abdominal pain has been identi-
ed should receive adequate analgesia. Judicious use of narcotic analgesia
has not been found to aect the reliability of the physical examination or
interfere with the diagnostic process in patients who have severe abdominal
pain [1113].
NSAIDs and acetaminophen may also diminish the fever response nor-
mally associated with infection or sepsis. Beta blockers and other negative
chronotropes may blunt the tachycardia that is associated with a stressed
physiologic state resulting from increased metabolic demands, fever, or hy-
povolemia. Normal blood pressure may not reect relative hypotension in
patients who are chronically hypertensive.
Age-related physiologic changes have been hypothesized as the reason for
which elderly patients have more frequent atypical presentations of abdom-
inal pain than their younger counterparts. These atypical features include
longer time until presentation, normothermia or even hypothermia, and
lower leukocyte counts in the face of serious intra-abdominal infections
[14,15]. It is accepted that other medical conditions, such as myocardial
Descargado de ClinicalKey.es desde Universidad El Bosque febrero 07, 2017. Para uso personal exclusivamente. No se permiten otros
usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.
 ABDOMINAL PAIN 257

ischemia, tend to present in the elderly with atypical symptoms [16], and this
principle may be extended to abdominal pathologic conditions.

History
Although history taking may be less reliable in older patients who have
abdominal pain, the clinician should try to obtain as complete a history
as possible. This should typically include
 Character: Clinicians should seek to distinguish between the dull, aching,
or gnawing pain suggestive of visceral pain and the characteristically
sharp, more dened and localized somatic pain associated with
peritonitis [17].
 Location: Embryologic origins of abdominal organs determine where a
patient will feel visceral pain. Foregut structures include the stomach,
pancreas, liver, biliary system, and proximal duodenum, with pain
typically localized to the epigastric region. The rest of the small intestines
and the proximal third of the colon (including the appendix) are
midgut structures, and the visceral pain associated with injury to these or-
gans is referred to the periumbilical region. Hindgut structures such as
the bladder, uterus, and distal two thirds of the colon usually cause
pain in the left lower quadrant or suprapubic region. Pain is usually re-
ported in the back for retroperitoneal structures such as the aorta and
kidneys [17].
 Onset: Acute-onset pain should alert the clinician to the possibility of an
intra-abdominal catastrophe, especially a perforated viscus, a ruptured
abdominal aortic aneurysm, or another vascular emergency. Unfortu-
nately, as mentioned previously, elderly patients may not present as ex-
pected; in one series of patients older than 70 years who had perforated
ulcers, only 47% reported sudden-onset pain [7]. Pain that has a gradual
onset is possible with a serious vascular issue, such as mesenteric
ischemia.
 Radiation: Radiation may be characteristic of a given disease (eg, radi-
ation from epigastrium to back in pancreatitis) or may reect the pro-
gression of disease (eg, continued aortic dissection or migration of
ureteral calculi).
 Intensity: Severe pain should raise concerns about a serious underlying
cause; however, descriptions of more mild pain should not dissuade the
clinician from further evaluation.
 Duration and progression: Persistent, worsening pain is worrisome,
whereas pain that grows less severe is typically favorable. Serious entities
generally present early, but delays may occur.
 Associated events: Anorexia, vomiting, diarrhea, and urinary symptoms
should be investigated. Pain frequently precedes vomiting in surgical
conditions [3].
Descargado de ClinicalKey.es desde Universidad El Bosque febrero 07, 2017. Para uso personal exclusivamente. No se permiten otros
usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.
 258 YEH & MCNAMARA

 Provocative and palliative factors: Pain with movement usually signies

peritoneal irritation; this is a key feature to discern during the interview.
Questions about how the trip to the oce/ED went will often prompt
the patient with peritoneal irritation to remark on an increase in pain
that occurred when hitting a bump. Pain after eating may reect peptic
ulcer disease, biliary disease, or mesenteric ischemia. The patient should
also be questioned about any self-treatments.
 Previous episodes: Recurrent episodes generally point to a medical
cause, with the exceptions of mesenteric ischemia (intestinal angina), bil-
iary disease, and partial bowel obstruction.

Physical examination
The general appearance of the patient is always important. An ill-ap-
pearing elderly patient is cause for great concern, given the high mortality
associated with abdominal pain in this patient population [2,3]. Conversely,
the clinician must not be misled by the well-appearing patient who has seri-
ous underlying disease [8].
As noted earlier, vital sign abnormalities such as fever, hypotension, and
tachycardia may be absent even in seriously ill patients. However, clinical
suspicion should be elevated when any of these abnormalities is noted,
because elderly patients frequently have a diminished reserve capacity.
Tachypnea may be noted secondary to pain, or it may be attributed to a
metabolic acidosis from sepsis or ischemic bowel. Inspection may reveal
distension in bowel obstructions. Auscultation may reveal high-pitched
sounds in small bowel obstruction. Fortunately, the location of tenderness
is generally a reliable guide to the underlying cause of the pain [18]. Guard-
ing and rigidity may be lacking because of laxity in the abdominal wall
musculature [6]. A disturbing nding is that only 21% of patients older
than 70 with a perforated ulcer presented with epigastric rigidity [7].
Although the diagnostic value of a rectal examination is minimal for
most acute conditions, it may be of use in mesenteric ischemia or in raising
suspicion for colon cancer. Further examination should include inspection
for hernias, pulsatile masses, and the quality of femoral pulses. Thorough
skin assessment may identify herpes zoster or signs of retroperitoneal hem-
orrhage, such Cullens sign or Grey Turners sign [19].

Diagnostic studies
Laboratory and ancillary tests
The signicant limitations of laboratory studies must be appreciated in
the evaluation of acute abdominal pain in the elderly. Many tests are non-
specic and, as previously discussed, may give a false sense of security when
Descargado de ClinicalKey.es desde Universidad El Bosque febrero 07, 2017. Para uso personal exclusivamente. No se permiten otros
usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.
 ABDOMINAL PAIN 259

they are normal. For example, the total leukocyte count may be normal in
the face of serious infection, such as appendicitis or cholecystitis. Specic
testing may be helpful in certain diagnoses, such as those of pancreatitis (li-
pase) or mesenteric ischemia (lactate), or in select circumstances, such as
a prothrombin time for a patient who is taking warfarin.

Radiographs
Plain abdominal radiographs are of limited utility in the evaluation of
acute abdominal pain. Although they may be helpful (eg, in identifying
free intraperitoneal air, calcied aortic aneurysm, air uid levels in obstruc-
tion), other diagnostic studies are almost always indicated or are preferable
as initial testing.

Ultrasound
Ultrasound is particularly useful in evaluating the gallbladder and pelvic
organs. Additionally, bedside ultrasound in the ED is useful in the older pa-
tient who presents with abdominal pain and hypotension. It can quickly re-
veal an abdominal aortic aneurysm, prompting early mobilization of the
surgical team. Ultrasound is limited by operator skill, bowel gas, and body
habitus.

Computed tomography
CT is frequently used in evaluation of the patient who has abdominal
pain [20]. Recent advances in the technology have allowed for improved im-
age resolution and shorter acquisition times. Coronal and three-dimensional
reconstruction signicantly enhance the detail of examinations. CT angio-
graphy has become more widespread and may be able to replace traditional
angiography as a means of evaluating mesenteric vessels [21]. The major lim-
itations of CT scanning are associated with intravenous contrast administra-
tion and include allergy and impaired renal function. CT scanning without
contrast can provide signicant information in a more expeditious fashion.
Judgment must be exercised in transporting an acutely ill patient away from
the resuscitation area.

Angiography
Angiography has long been the gold standard for evaluation of the ab-
dominal aorta and mesenteric vascular structures. Although alternative
imaging modalities such as MRI and CT have an increasing role [22], insti-
tutional and clinician preferences for angiography still exist. Additionally,
angiography plays a signicant role in therapy for certain diagnoses.
Descargado de ClinicalKey.es desde Universidad El Bosque febrero 07, 2017. Para uso personal exclusivamente. No se permiten otros
usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.
 260 YEH & MCNAMARA

Specic diagnoses
Bowel obstruction
Small bowel obstruction (SBO) is one of the most common reasons for
surgical intervention in patients who have abdominal pain. The most com-
mon risk factor, namely previous abdominal surgery resulting in adhesions,
is patient specic and not necessarily age related [23]. Surgical intervention
may be necessary for lysis of adhesions, repair of incarcerated hernias, and
bowel resection [24]. Abdominal pain, distension, and vomiting are typically
present, and the diagnosis is usually straightforward. Delayed diagnosis is
associated with increased mortality and morbidity in patients requiring sur-
gical management [25]. CT will typically reveal dilated loops of bowel and
air uid levels (Fig. 1). On occasion, a transition point may be seen, where
there is evidence of distended bowel followed by normal bowel.
Large bowel obstruction (LBO) is less common than SBO, but its preva-
lence rises with aging along with that of its most common causes (colon
cancer and diverticulitis) (Fig. 2) [6]. Sigmoid and cecal volvulus are other
entities associated with LBOs. Although vomiting and constipation are typ-
ically expected in LBO, they are not always present [23]. Most causes of
LBOs require surgical intervention. However, some cases of sigmoid volvu-
lus may be decompressed initially by sigmoidoscopy to allow for medical
resuscitation as needed before denitive operative intervention [26].

Biliary tract disease

The incidence of cholelithiasis increases with age; studies report a preva-
lence ranging from 3% to 18% of the population. It is hypothesized that

Fig. 1. CT showing dilated loops of small bowel with air uid levels suggestive of small bowel
obstruction.

Descargado de ClinicalKey.es desde Universidad El Bosque febrero 07, 2017. Para uso personal exclusivamente. No se permiten otros
usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.
 ABDOMINAL PAIN 261

Fig. 2. Large bowel obstruction (arrow) due to a colon mass.

decreased responsiveness to cholecystokinin and depressed gallbladder mo-

tility predispose the older patient to stone formation [27]. Symptomatic dis-
eases typically require surgery or endoscopic intervention and include biliary
colic (calculous or acalculous), cholecystitis, gallstone pancreatitis, and
choledocolithiasis. In the setting of acute cholecystitis in an elderly patient,
it is highly recommended that one initiate the operative procedure with min-
imal delay, because delays are associated with signicantly increased mor-
bidity [28]. Nonoperative management in patients older than 80 can result
in mortality as high as 17% [29]. Elderly patients tend to have the typical
right upper quadrant or epigastric pain, but more than half of elderly pa-
tients with acute cholecystitis do not have nausea and vomiting, and a signif-
icant proportion do not have fever [30]. Ultrasound is frequently used in the
evaluation of right upper quadrant pain (Fig. 3). But if no gallbladder stones
are found and clinical suspicion for cholecystitis is still high, radionuclide
scanning/cholescintigraphy should be performed.

Appendicitis
Appendicitis accounts for approximately 5% of all cases of acute abdo-
men in the elderly [31]. Less than one third of elderly patients have the clas-
sic presentation, dened as including all of the following: fever, elevated
white blood cell count, anorexia, and right lower quadrant pain. The di-
cult nature of this disease in the elderly is reected in the literature. For ex-
ample, in one series, 54% of older patients who had appendicitis had an
incorrect initial admitting diagnosis, which contributed to the high perfora-
tion rate (51%) found at the time of surgery [32]. The delay in presentation
Descargado de ClinicalKey.es desde Universidad El Bosque febrero 07, 2017. Para uso personal exclusivamente. No se permiten otros
usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.
 262 YEH & MCNAMARA

Fig. 3. Ultrasound of gallbladder with acoustic shadowing from gallstones.

of the patients was also reported as a factor contributing to increased com-

plication rates. Many factors may deect attention from appendicitis as the
cause of the patients pain, including lack of the classic symptoms, absence
of fever and leukocytosis (in as many as 20% of patients), and clinical fea-
tures suggesting an alternative diagnosis, such as urinary tract infection (fre-
quency, pyuria) or gastroenteritis (diarrhea). Importantly, right lower
quadrant pain and tenderness are usually present, and appendicitis must re-
main high on the list of diagnostic possibilities when these symptoms are dis-
covered. Although CT scanning (Fig. 4) has aided in the diagnosis of
appendicitis in patients who have abdominal pain [33], its sensitivity is

Fig. 4. CT showing inamed appendix and periappendiceal fat stranding (arrow).

Descargado de ClinicalKey.es desde Universidad El Bosque febrero 07, 2017. Para uso personal exclusivamente. No se permiten otros
usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.
 ABDOMINAL PAIN 263

not 100%, and admission for observation is prudent when the cause of
lower abdominal pain is unclear.

Abdominal aortic aneurysm

The diagnosis of ruptured abdominal aortic aneurysm (AAA) should be
the rst consideration in an older patient who has abdominal, back, ank, or
groin pain and hypotension. The presence of a pulsatile abdominal mass on
examination or bedside ultrasound will clinch the diagnosis. Unfortunately,
the clinical features sometimes lead clinicians astray, especially when hypo-
tension is absent. The most common misdiagnoses include renal colic and
diverticulitis [34,35]. It is prudent to consider investigation for AAA when-
ever renal colic is suspected in elderly patients. Ruptured AAA carries mor-
talities from 15% to 50%, with rates approaching 90% when patients are in
shock [35]. Early diagnosis and an aggressive approach represent the pa-
tients best chance for survival. The need to have diagnostic certainty before
operation should be tempered by the potentially serious consequences of
delay. It should also be considered that most patients who are operated
on for suspicion of this condition and turn out not to have a ruptured
AAA do have another disease that requires laparotomy [36].
CT angiography is the test of choice in stable patients because of its abil-
ity to detect aneurysm as well as rupture or leak (Fig. 5). Given that
approximately 90% of AAAs are infrarenal, the CT angiogram can assist
the surgeons in their operative approach [37]. Non-contrast CT may be con-
sidered in patients who have contrast allergies or renal insuciency. In
unstable patients, bedside ultrasound examination may also be used to

Fig. 5. Contrast CT showing proximal abdominal aortic aneurysm with mural thrombus.

Descargado de ClinicalKey.es desde Universidad El Bosque febrero 07, 2017. Para uso personal exclusivamente. No se permiten otros
usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.
 264 YEH & MCNAMARA

identify AAA rapidly [38]. Emergent operative intervention should occur as

soon as possible when a ruptured AAA is identied [34,35].

Bowel perforations
Peptic ulcers are one of the most common causes of bowel perforations
[6]. The expected presentation begins with a report of the sudden onset of
severe epigastric pain, with subsequent development of evidence of peritoni-
tis on physical examination. However, this pattern is less common in the el-
derly. The atypical presentation in the elderly frequently leads to delays or
failures in making the diagnosis. Many elderly patients present with minimal
abdominal pain [7], and the presence of an underlying peptic ulcer is fre-
quently obscured by the lack of pain in such patients [39]. Often the patient
reports no history of peptic ulcer disease [40]. Although the nding of free
air on plain radiographs (usually an upright or lateral chest radiograph)
aids in the diagnosis, its absence should not be used to exclude one; these
studies do not show pneumoperitoneum in as many as 40% of patients
who have perforated ulcers [40]. CT is highly sensitive for free air (Fig. 6).
Although nonoperative management is sometimes considered in younger
patients, patients older than 70 are less likely to have a favorable outcome
with a nonsurgical approach [41]. Colon cancer and diverticular disease
are responsible for most other bowel perforations in the elderly, especially
because the incidence of these entities increases with age [42]. The presenta-
tion of such perforations varies with the location, extent of leakage, and re-
sponse of the patient. The diagnosis is often not clear until CT or operative
intervention is employed in a patient who has suspected peritonitis.

Fig. 6. Perforated gastric ulcer with free air and massive ascites.

Descargado de ClinicalKey.es desde Universidad El Bosque febrero 07, 2017. Para uso personal exclusivamente. No se permiten otros
usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.
 ABDOMINAL PAIN 265

Diverticular disease
Diverticular disease may present as abdominal pain, lower gastrointesti-
nal bleeding, an acute abdomen from perforated diverticula, or a large
bowel obstruction. Pain usually begins in the hypogastric region and local-
izes to the left lower quadrant. Diarrhea and constipation have both been
reported as alterations in bowel habits. Although diverticulitis may often
be diagnosed clinically in patients who have a history of diverticulosis, el-
derly patients should typically undergo imaging (Fig. 7). Contrast CT of
the abdomen and pelvis is usually the test of choice, because colonoscopy
and rectal contrast enemas may carry a risk for perforation during the acute
phase.
Mild cases may be treated with oral antibiotics and a clear liquids diet in
patients who have close follow-up. However, it has been suggested that it is
appropriate to admit elderly patients for intravenous antibiotics and close
observation, because of the potential for rapid progression of gram-nega-
tive sepsis [43]. Peridiverticular abscesses may be treated by means of
CT-guided drainage, whereas laparotomy for colonic resection should still
be performed in cases of frank perforation. Surgical consultation should
also be considered for patients who do not improve with medical
management.

Pancreatitis
In the elderly, pancreatitis is less often caused by alcohol abuse than in
younger patients; gallstones are responsible in as many as 70% of patients
older than 80 years. No cause of pancreatitis can be identied in as many
as 15% to 30% of cases in older patients [44]. Classic symptoms are a steady,

Fig. 7. Coronal CT showing multiple diverticulae in descending colon.

Descargado de ClinicalKey.es desde Universidad El Bosque febrero 07, 2017. Para uso personal exclusivamente. No se permiten otros
usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.
 266 YEH & MCNAMARA

boring pain radiating to the back, associated with nausea, vomiting, and de-
hydration. Progression of pancreatitis may mimic systemic inammatory re-
sponse syndrome and is believed to be triggered by a variety of
inammatory mediators [45]. As a result, elderly patients frequently present
in shock, and necrotizing pancreatitis represents the most lethal complica-
tion, especially in patients older than 80 [46]. Serum amylase and lipase
may aid in the diagnosis of acute pancreatitis, but CT (Fig. 8) should almost
always be considered in the work-up, because other diagnoses may need to
be excluded. Endoscopic or surgical therapy may be considered in gallstone
pancreatitis, whereas CT-guided drainage may be performed in cases of ab-
scess or limited necrosis. Surgical debridement is usually only considered in
refractory or severe cases.

Mesenteric ischemia
Delayed diagnosis of mesenteric ischemia (MI) is frequent and carries
a high mortality, with rates of 45% to 90% depending on causation of
the event [47]. MI may be caused by either nonocclusive infarction or occlu-
sion from an embolus or thrombus. The superior mesenteric artery is most
frequently involved in acute and chronic occlusions, but the inferior mesen-
teric artery and the mesenteric vein can be aected [47]. Risk factors include
cardiac dysrhythmias (particularly atrial brillation), myocardial infarction,
congestive heart failure, peripheral vascular disease, embolic disease, and
hypotensive states.
Typical symptoms include the gradual onset of abdominal pain (though
an embolus may present with sudden pain), which progresses in severity
over time and is refractory to narcotic analgesics. The early abdominal

Fig. 8. CT with complex pancreatic mass (arrow).

Descargado de ClinicalKey.es desde Universidad El Bosque febrero 07, 2017. Para uso personal exclusivamente. No se permiten otros
usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.
 ABDOMINAL PAIN 267

examination is usually benign despite the severity of the pain, and this asso-
ciation is a key diagnostic clue. Nausea, vomiting, and diarrhea are com-
mon, and the clinician must be careful not to attribute those symptoms
reexively to gastroenteritis. Late ndings of peritonitis and shock are om-
inous signs.
Nonocclusive ischemia develops from hypoperfusion [48] and can occur
in patients hospitalized for other reasons, including sepsis, dehydration,
and heart failure [49]. Leukocytosis and lactic acidosis are generally present
and may increase suspicion for MI. Plain lms are generally nonspecic. Use
of CT (Figs. 9 and 10) and CT angiography is more common and may also
provide insight into other disease states. Angiography can provide both a di-
agnostic option for identifying the extent of vessel involvement and a thera-
peutic option for the infusion of vasodilatory agents or thrombolytics [50].
Treatment is primarily surgical but may involve a combination of angiogra-
phy and laparotomy [51]. Even with intervention, MI carries a high mortal-
ity in the setting of multisystem organ failure [52].

Other conditions and causes

In addition to the conditions reviewed in this section, numerous other
surgical and nonsurgical entities can cause abdominal pain in the elderly.
Aortic dissection, intussusception, gastric volvulus, and ischemic colitis
are on the list of conditions that may require surgical intervention. Impor-
tant nonsurgical diseases may also present with abdominal pain. First and
foremost on this list is acute myocardial ischemia, which should always be
considered in the elderly patient who has upper abdominal pain. Virtually

Fig. 9. Pneumatosis, free air, and air in portal vein in a patient with ischemic colon.

Descargado de ClinicalKey.es desde Universidad El Bosque febrero 07, 2017. Para uso personal exclusivamente. No se permiten otros
usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.
 268 YEH & MCNAMARA

Fig. 10. Air in liver from portal system.

every other chest disease can present with abdominal pain, including pneu-
monia, pulmonary embolism, empyema, and congestive heart failure. The
genitourinary system should not be overlooked: renal colic, pyelonephritis,
epididymitis, testicular torsion, ovarian cancer, and Fourniers gangrene are
important causes in the elderly. Diabetic ketoacidosis, herpes zoster, hyper-
calcemia, Addisonian crisis, hemochromatosis, and hematomas of the rectus
sheath or retroperitoneum in anticoagulated patients are some medical
causes of abdominal pain in the elderly.

Summary
Abdominal pain in the elderly has numerous causes. A prudent approach
involves routine and early consideration of the life-threatening pathologic
conditions and recognition that serious disease may be very dicult to diag-
nose. Atypical presentations of abdominal diseases are common in the el-
derly. This problem contributes to delays in diagnosis and treatment and
thus, unfortunately, to increased mortality and morbidity. The complaint
of abdominal pain in an elderly patient must be considered seriously. It
may require referral to an ED, extensive diagnostic testing, surgical consul-
tation, and consideration of admission for observation until the patients
condition is claried.

References
[1] U.S. Census Bureau. The elderly population. Available at: http://www.census.gov/
population/www/pop-prole/elderpop.html. Accessed July 20, 2006.

Descargado de ClinicalKey.es desde Universidad El Bosque febrero 07, 2017. Para uso personal exclusivamente. No se permiten otros
usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.
 ABDOMINAL PAIN 269

[2] Kizer KW, Vassar MJ. Emergency department diagnosis of abdominal disorders in the el-
derly. Am J Emerg Med 1998;16:35762.
[3] Brewer RJ, Golden GT, Hitch DC, et al. Abdominal pain: an analysis of 1,000 consecutive
cases in a university hospital emergency room. Am J Surg 1976;131:21924.
[4] Baum SA, Rubenstein LZ. Old people in the emergency room: age-related dierences in
emergency department use and care. J Am Geriatr Soc 1987;35:398404.
[5] Ciccone A, Allegra JR, Cochrane DG, et al. Age related dierences in diagnoses within the
elderly population. Am J Emerg Med 1998;16:438.
[6] Hendrickson M, Naparst TA. Abdominal surgical emergencies in the elderly. Emerg Med
Clin North Am 2003;21:93769.
[7] Fenyo G. Acute abdominal disease in the elderly: experience from two series in Stockholm.
Am J Surg 1982;143:7514.
[8] Fenyo G. Diagnostic problems of acute abdominal diseases in the aged. Acta Chir Scand
1974;140:396405.
[9] Martinez JP, Mattu A. Abdominal pain in the elderly. Emerg Med Clin North Am 2006;24:
37188.
[10] Bender JS. Approach to the acute abdomen. Med Clin North Am 1989;14:141322.
[11] Thomas SH, Silen W, Cheema F, et al. Eects of morphine analgesia on diagnostic accuracy
in emergency department patients with abdominal pain: a prospective, randomized trial.
J Am Coll Surg 2003;196:1831.
[12] Gallagher EJ, Esses D, Lee C, et al. Randomized clinical trial of morphine in acute abdom-
inal pain. Ann Emerg Med 2006;48:15060.
[13] Wolfe JM, Smithline HA, Phipen S, et al. Does morphine change the physical examination in
patients with acute appendicitis? Am J Emerg Med 2004;22:805.
[14] Cooper GS, Shlaes DM, Salata RA. Intraabdominal infection: dierences in presenta-
tion and outcome between younger patients and the elderly. Clin Infect Dis 1994;19:
1469.
[15] Parker JS, Vukov LF, Wollan PC. Abdominal pain in the elderly: use of temperature and
laboratory testing to screen for surgical disease. Fam Med 1996;28:1937.
[16] Bayer AJ, Chadha JS, Farag RR, et al. Changing presentation of myocardial infarction with
increasing old age. J Am Geriatr Soc 1986;34:2636.
[17] Jones RS, Claridge JA. Acute abdomen. In: Townsend CM, Beauchamp RD, Evers BM,
et al, editors. Sabiston textbook of surgery: the biologic basis of modern surgical practice.
17th edition. Philadelphia: Elsevier; 2004. p. 121938.
[18] McNamara R. Abdominal pain in the elderly. In: Tintinalli JE, Kelen GD, Stapczynski S,
et al, editors. Emergency medicine: a comprehensive study guide. 6th edition. New York:
McGraw-Hill; 2004. p. 5015.
[19] Marinella MA. Cullens sign. Hosp Physician 1999;35:356.
[20] Esses D, Birnbaum A, Bijur P, et al. Ability of CT to alter decision making in elderly patients
with acute abdominal pain. Am J Emerg Med 2004;22:2702.
[21] Martinez JP, Hogan GJ. Mesenteric ischemia. Emerg Med Clin North Am 2004;22:
90928.
[22] Chow LC, Chan FP, Li KC. A comprehensive approach to MR imaging of mesenteric ische-
mia. Abdom Imaging 2002;27:50716.
[23] Kahi CJ, Rex DK. Bowel obstruction and pseudo-obstruction. Gastroenterol Clin North
Am 2003;32:122947.
[24] Foster NM, McGory ML, Zingmond DS. Small bowel obstruction: a population-based
appraisal. J Am Coll Surg 2006;203:1706.
[25] Schwab DP, Blackhurst DW, Sticca RP. Operative acute small bowel obstruction: admitting
service impacts outcome. Am Surg 2001;67:10348.
[26] Mahmoud N, Rombeau J, Ross HM, et al. Colon and rectum. In: Townsend CM,
Beauchamp RD, Evers BM, et al, editors. Sabiston textbook of surgery: the biologic
basis of modern surgical practice. 17th edition. Philadelphia: Elsevier; 2004. p. 140181.

Descargado de ClinicalKey.es desde Universidad El Bosque febrero 07, 2017. Para uso personal exclusivamente. No se permiten otros
usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.
 270 YEH & MCNAMARA

[27] Walsh RM. Innovations in treating the elderly who have biliary and pancreatic disease. Clin
Geriatr Med 2006;22:54558.
[28] Glenn F. Surgical management of acute cholecystitis in patients 65 years of age and older.
Ann Surg 1980;193:569.
[29] Arthur JDR, Edwards PR, Chagla LS. Management of gallstone disease in the elderly. Ann
R Coll Surg Engl 2003;85:916.
[30] Morrow DJ, Thompson J, Wilson SE. Acute cholecystitis: a surgical emergency. Arch Surg
1978;113:114952.
[31] Kauvar DR. The geriatric acute abdomen. Clin Geriatr Med 1993;9:54758.
[32] Storm-Dickerson TL, Horatta MC. What have we learned over the past 20 years about ap-
pendicitis in the elderly? Am J Surg 1983;185:198201.
[33] Gupta H, Dupuy DE. Abdominal emergencies: has anything changed? Surg Clin North Am
1997;77:124564.
[34] Marston WA, Ahlquist R, Johnson G Jr, et al. Misdiagnosis of ruptured abdominal aortic
aneurysms. J Vasc Surg 1992;16:1722.
[35] Johansen K, Kohler TR, Nicholls SC, et al. Ruptured abdominal aortic aneurysm: the Har-
borview experience. J Vasc Surg 1991;13:2407.
[36] Valentine RJ, Barth M, Myers S, et al. Nonvascular emergencies presenting as ruptured
abdominal aortic aneurysms. Surgery 1993;113:2869.
[37] Siegel CL, Cohan RH. CT of abdominal aortic aneurysms. AJR Am J Roentgenol 1994;163:
1729.
[38] Kuhn M, Bonnin RL, Davey MJ, et al. Emergency department ultrasound scanning for ab-
dominal aortic aneurysm: accessible, accurate, and advantageous. Ann Emerg Med 2000;36:
2139.
[39] Hilton DH, Iman N, Burke GJ, et al. Absence of abdominal pain in older persons with en-
doscopic ulcers: a prospective study. Am J Gastroenterol 2001;96:3804.
[40] Borum ML. Peptic-ulcer disease in the elderly. Clin Geriatr Med 1999;15:45771.
[41] Crofts TJ, Park KG, Steele RJ, et al. A randomized trial of nonoperative treatment for per-
forated peptic ulcer. N Engl J Med 1989;320:9703.
[42] Shoji BT, Becker JM. Colorectal disease in the elderly patient. Surg Clin North Am 1994;74:
293316.
[43] Farrell RJ, Farrell JJ, Morrin MM. Diverticular disease in the elderly. Gastroenterol Clin
North Am 2001;30:47596.
[44] Martin SP, Ulrich CD II. Pancreatic disease in the elderly. Clin Geriatr Med 1999;15:
579605.
[45] Bentrem DJ, Joehl RJ. Pancreas: healing response in critical illness. Crit Care Med 2003;
31(Suppl):S5829.
[46] Paajanen H, Jaakkola M, Oksanen H, et al. Acute pancreatitis in patients over 80 years. Eur
J Surg 1996;162:4715.
[47] Newman TS, Magnuson TH, Ahrendt SA, et al. The changing face of mesenteric infarction.
Am Surg 1998;64:6116.
[48] Park WM, Gloviczki P, Cherry KJ, et al. Contemporary management of acute mesenteric
ischemia: factors associated with survival. J Vasc Surg 2002;35:44552.
[49] Bassiouny HS. Nonocclusive mesenteric ischemia. Surg Clin North Am 1997;77:31926.
[50] Glenister KM, Corke CF. Infarcted intestine: a diagnostic void. ANZ J Surg 2004;74:2605.
[51] Freeman AJ, Graham JC. Damage control surgery and angiography in cases of acute mes-
enteric ischemia. ANZ J Surg 2005;75:30814.
[52] Edwards MS, Cherr GS, Craven TE, et al. Acute occlusive mesenteric ischemia: surgical
management and outcomes. Ann Vasc Surg 2003;17:729.

Descargado de ClinicalKey.es desde Universidad El Bosque febrero 07, 2017. Para uso personal exclusivamente. No se permiten otros
usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.